The moment statute gives monopoly, forced membership, and taxation
powers to this sort of organization, it’s as good as government.

> As far as I’m concerned, dogma is irrelevant; all that matters is results.

Fair enough. Thing is, there is evidence that the socialized medicine like
you’re describing does not actually have good results in the long run, at
least from what I have read and personally observe (living under one such
system). It’s expensive and the service is worse (by some measures). We
can argue about which measures to use, but then we’re back to ideology.

> * Unless it is run with greater mathematical honesty than contemporary
> government entitlement programs, there will be a temptation for political reasons
> to turn it into a Ponzi scheme like so many others - where future generations are
> made to pay more than current ones. This is especially cruel with an overall aging
> population.

There is no special reason that it has to be run by the government. It needs to be enabled by the government. But it can be a private for-profit company, like the electrical utilities or Fannie Mae, or it can be a private non-profit organization, like (in practice) the Post Office. Sure, there is plenty of scope of corruption and inefficiency. But it’s not like we don’t have that today. The question is not whether it would be perfect–of course it wouldn’t–but whether it would be an improvement.

> * Not only can’t there be a way out for healthy people (for then the subsidy effect
> would not work), but there also can’t be an easy way out for sick but wealthy
> people either (for political reasons - the rest of the population would moan about
> how the “rich” are getting better service, despite being forced to pay all their lives).

If that were true, then people in the U.S. would moan about the rich all the time. In point of fact, the rich always get better service, and they even pay taxes at a lower rate (although they do pay more actual cash). Hardly anybody cares. Wealthy people in the U.S. would certainly be able to purchase better health care under any imaginable scheme–if nothing else, they would just go off-shore, so why not keep them in the country.

> * It generates anti-incentives to try to stay healthy; to use the medical system
> sparingly (”I already paid - of course I’ll go to Emergency for my flu.”). That in turn
> spirals the costs upwards - check out Canada’s federal/provincial budget
> allocations.

Every medical visit would have a co-payment, just like today. And there would presumably be a deductible, just like today. And there would be some scheme to refund the money to the very poor, like the earned income tax credit. I don’t see any reason to give up the good lessons learned from HMOs, while abandoning the bad ones.

> * Other market distortions of a single payer scheme; no reason for competition
> between hospitals (since the fees need to be standardized — or do you envision
> the equivalent of transferable school vouchers?).

I agree that the fees would need to be standardized, but so what? A hospital which can provide good care at lower cost will make put more money into the pockets of its owners. And the fees would be set to permit some profit, so hospitals would still want as many patients as they could handle well. I see plenty of room for competition.

> It’s socialism - well-intentioned as always, but in practice rarely works out for long.

I’m not sure exactly what you mean by “socialism” here, but I doubt that I see anything wrong with it. I think most people would agree that we run our police and fire departments following socialist principles, and they seem to work well enough. As far as I’m concerned, dogma is irrelevant; all that matters is results.

Such a scheme (forced lifelong savings program combined with a forced homogenous insurance pool) has some odd properties:

* Unless it is run with greater mathematical honesty than contemporary government entitlement programs, there will be a temptation for political reasons to turn it into a Ponzi scheme like so many others - where future generations are made to pay more than current ones. This is especially cruel with an overall aging population.

* Not only can’t there be a way out for healthy people (for then the subsidy effect would not work), but there also can’t be an easy way out for sick but wealthy people either (for political reasons - the rest of the population would moan about how the “rich” are getting better service, despite being forced to pay all their lives).

* It generates anti-incentives to try to stay healthy; to use the medical system sparingly (”I already paid - of course I’ll go to Emergency for my flu.”). That in turn spirals the costs upwards - check out Canada’s federal/provincial budget allocations.

* Other market distortions of a single payer scheme; no reason for competition between hospitals (since the fees need to be standardized — or do you envision the equivalent of transferable school vouchers?).

It’s socialism - well-intentioned as always, but in practice rarely works out for long.

Tempting in a way, but we know it won’t happen. When somebody will die without medical care, we will give them medical care. Maybe not the very best medical care, but we will do something. To act any other way would be immoral.

> If instead we build a system that is explicitly tweaked to subsidize the
> old & sick, then we’re going to have to lose the presumption of lower cost
> (economic efficiency), and factors like governmental interference etc. come
> in too.

I don’t know whether a single payer system is the right answer. But, if it is, it is not the case of explicitly tweaking the system to subsidize the old and sick. The point of a single payer system is that everybody goes into the same insurance pool. Everybody pay premiums which are based on their expected future expenditures (in a governmental based single payer system, these premiums take the form of taxes, but single payer is not inherently run by the government). The very great majority of us do in fact become old and/or sick. Therefore, our premiums are set accordingly. By doing so we are not subsidizing the old and sick, although they will receive most of the benefits at any given time. We are paying a fee which will cover our future health care.

(How about … by themselves?)

OK, but then we are ditching insurance concepts like random risk pools.

If instead we build a system that is explicitly tweaked to subsidize the
old & sick, then we’re going to have to lose the presumption of lower cost
(economic efficiency), and factors like governmental interference etc. come
in too.

It’s certainly true that a single payer system would reduce costs for society while increasing costs for a healthy individual. But to judge properly, you have look at the entire lifespan. Somebody who is healthy until he or she dies in a car accident at age 30 should, considered alone, pay for health care a la carte. But, barring significant changes in health care practice, anybody who lives to the age of 75 is going to face significant health care expenses, which must be borne by somebody.

One way to look at a single payer system is that it forces everybody into a single insurance pool, and thus permits the insurer to use valid statistics when computing premiums. That will inherently increase costs for some people–that is the nature of insurance. But if it works well, it should decrease costs over all.

> Lots of people talk about reducing costs by moving to a single payer
> system, which certainly makes sense to me.

For a healthy individual, that scenario (arguendo) could decrease the former
but increase the latter.

The rich get the most advanced treatment. This develops new procedures.

Once the procedures are developed, they are cost reduced.

As time goes on more and more people can afford them.

Most of the problem with health care is that it is mostly third party payers. Thus the “auditing” of the players is not up close and personal.

I don’t think U.S. doctors literally have a union. There are licensing requirements, which amount to the same thing.

Also, while doctors are indeed well paid, I doubt their salaries amount to more than 5% or so of health care costs. And I’ve never heard that we have a general shortage of doctors. We have shortages in specific fields (e.g., people willing to perform abortions), and shortages in specific areas (e.g., inner cities and rural areas), but there is not a general shortage.

So I’m not convinced that permitting more doctors to enter the country will have a significant effect on health care costs. Not that I’m opposed to the idea. I just don’t think it will make much difference to costs.

We do have a shortage of nurses in the U.S. That shortage could be partially alleviated by permitting nurses to enter the country, and I think that would be a good idea. However, nurses are not particularly well paid, so that would have little effect on health care costs.